Provider Demographics
NPI:1144668294
Name:FULTZ, MELISHA KANISH (MS LPC)
Entity type:Individual
Prefix:MRS
First Name:MELISHA
Middle Name:KANISH
Last Name:FULTZ
Suffix:
Gender:F
Credentials:MS LPC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5109 S MADISON AVE
Mailing Address - Street 2:APARTMENT 146
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-5682
Mailing Address - Country:US
Mailing Address - Phone:918-856-1915
Mailing Address - Fax:918-293-2581
Practice Address - Street 1:1013 E 66TH PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3701
Practice Address - Country:US
Practice Address - Phone:918-293-2500
Practice Address - Fax:918-293-2581
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program